Transport Support to Improve ARV Treatment Outcomes

Transportation challenges to pick up HIV medication is a major barrier to continued HIV treatment in resource-limited countries. Our data suggest that treatment interruptions due to transport barriers accessing medications account for 90% of missed doses, that these increase with distance to clinic, and are a major cause of ARV resistance. Nevirapine fixed-dose combination therapy is particularly vulnerable to treatment interruptions due to differing half-lives and a subsequent “nevirapine tail” during interruptions. We propose to determine the behavioral, biologic and economic impact of monthly transportation assistance over 12 months in a rural African HIV treatment setting. We will specifically look at how transportation assistance impacts the following:

* Behavioral Outcomes. We will determine the impact of transportation assistance on reducing treatment interruptions.

* Biologic Outcomes. We will determine the impact of transportation assistance on HIV viral suppression.

* Economic Outcomes. We will determine the impact of transportation assistance on economic productivity.

We will conduct a randomized trial of monthly transportation to clinic concurrent with refill dates and physician visits compared to standard care (no transportation provided) among 200 people attending the Mbarara University HIV Clinic in rural southwestern Uganda. We will provide morning transportation from the participant's residence to clinic on the prearranged time and date each month to pick up refills and see a health care provider. We will coordinate with the clinic and pharmacy to schedule the same return dates for patients in a common geographic region. Participants will be given funds for return transportation via available mini-bus or bicycle taxi. The comparison group will arrange self transportation to clinic each month as is customary for the current standard of care in Mbarara, Uganda. Structured interviews regarding medication/health service use, functional health status, and economic variables will be conducted every 3 months. HIV viral load and CD4 cell count will be collected at baseline and 12 months.

To determine whether transportation assistance is associated with fewer treatment interruptions, we will compare total days of interrupted therapy, number of 48 hour treatment interruptions, and pharmacy refill behavior between the two groups. To determine whether transportation assistance is associated with HIV viral load suppression, we will compare HIV viral load between the two groups. To determine whether transportation assistance improves the economic output, we will examine the effects of transportation assistance on labor supply, household consumption, child labor and schooling hours, and loans received in order to determine the full benefit of transportation assistance.